lt col kevin j. bohnsack dsn 580.3565, comm 269.969.3565 [email protected] 110 mdg/sgp
DESCRIPTION
Aircraft Mishap Response and Investigation. Lt Col Kevin J. Bohnsack DSN 580.3565, Comm 269.969.3565 [email protected] 110 MDG/SGP. You get the call…. …so now what do you do?. Notification Resources Immediate Response Interim Safety Board Evidence Collection - PowerPoint PPT PresentationTRANSCRIPT
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Lt Col Kevin J. BohnsackDSN 580.3565, Comm 269.969.3565
[email protected] MDG/SGP
Aircraft Mishap Response and
Investigation
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You get the call…
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…so now what do you do?
NotificationResources Immediate Response Interim Safety Board
– Evidence Collection– Aircrew & Witness Interviews
Additional Considerations– PA– Mishap Classifications
Safety/Accident Investigation BoardsHuman Factors Analysis
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Source Documents
AFI 91-202 AIR NATIONAL GUARD Supplement to AFI 91-202AFI 91-204 Safety Investigations and ReportsAFI 51-503 Aerospace Accident InvestigationAFI 91-206 Participation in a Military or Civilian
Accident Safety Investigation (NTSB)AFPAM 91-211 USAF Guide to Safety Investigation
The Society of United States Air Force Flight Surgeons Aircraft Mishap Investigation Handbook (Sixth edition dated April 2010)
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Flight Surgeon Handbook and AFPAM 91-211
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Assistance
Chain of Command Wing Safety Air Force Safety Center (AFSC)– Human Factors Division:
Flight Surgeon (DSN 263-4868, Comm 505-853-4868) – Col Berg
Aerospace Physiology (DSN 246-0986) – Maj Tugliese Pilot (DSN 246-0830, Comm 505-846-0830)
– Aircraft Engineering Technical Assistance (DSN 246-5867 or comm 505-846-5867)
Armed Forces Medical Examiner System (AFMES), formerly known as the Armed Forces Institute of Pathology (AFIP)
National Guard Bureau (NGB)
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Resources / Thanks
Air Force Safety Center
Division of Forensic Toxicology Armed Forces Medical Examiner System
Building 115, Purple Heart DriveDover AFB, DE 19902
DSN: 366-8724 Phone: (302) 346-8724
Col William Pond, Indiana ANG SAS– Recommend: Pond’s Pearls
Lt Col David Hardy, RAM ‘09 BravoLt Col Fred Black, North Dakota ANGMSgt Michelle Saatoff, North Dakota ANG
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Notification
WHO – Aircrew, souls on board, first responders (fire, security,
medical, safety, and BEE’s)WHAT
– Aircraft type, materials on board (tower, manifest)WHERE
– On- or off-base, environment (woods, water, current weather)WHEN
– Anticipated duration of response (e.g. food, water)– Time constraints (e.g. safety, time of day, predicted weather)
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Resources
Mishap Investigation Kit– Medical supplies– Nitrile gloves, leather gloves, Tyvek suit, dust mask– Digital camera, photographic ruler, grease pen, evidence
collection tags– Lab collection vials / needles – KEEP THEM CURRENT IF
YOU CHOOSE TO HAVE THOSE AVAILABLE!Clothing
– Cold weather or rain gear– Boots
Infrastructure– Tentage / Comm / Trans – “For want of a nail.”– Food / Water – “An army marches on its stomach.” -Napoleon
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Site Hazards
Scene Safe– Follow direction of OSC (usually Fire Chief)
PPE– Follow direction of OSC & BEE’s
Know what hazards you are dealing with! – Survey the Site!– Know toxic substances unique to aircraft
Limit access to site– Brief all personnel on hazards before entry
Don’t put your hands where you can’t see! (sts)
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Site Hazards
Environmental Hazards– Hot, cold, sun, wind, rain, snow, “critters”
Biological Hazards– Blood borne Pathogens
Fire Hazards– Fuel– Other fluids
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Site Hazards
Radioactive Hazards– Control Surface Counterweights = depleted
uraniumMaterial Hazards
– Composites – Explosives (ammo, pyrotechnics, etc)– Pressure Vessels (tires, O2 cylinders, etc)– Sharp Edges
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Composites
F-15 F-16 F-117 B-2 Atlas V
U-2F-22F-14B-1BDelta IV
Defer to Fire Department regarding materials involved.
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Site Hazards/PPE
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Site Hazards
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Site Hazards/PPE
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Site Hazards
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Site Hazards
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Immediate Response
Patient Care– Treat injuries– Obtain information of medical necessity (Information
re: the mishap sequence is potentially privileged information.)
– 72 hour and 2 week history– Separate crew members if at all possible for interviews
under direction of the Interim Safety Board (ISB)(Treatment of Survivors checklist is useful from
the Handbook)
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Identification
Obtain accurate flight manifest/SSNs– Allows DNA cards to be pulled quickly
Identifies all flight crew & passengersSurvivability assessmentClosure for family
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Identification
Presumptive - identifies individual to sub-group (initial)
Positive - legal identification based on forensics
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Presumptive Identification
Flight manifestVisual (tattoos)AnthropomorphicPersonnel dataPersonal effects
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Positive Identification
DentalFingerprintsPalm printsFoot printsDNARadiographic ID
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Positive ID timeframe
Dental 1 - 2 hoursFingerprints 24 - 48 hoursDNA 48 hours
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Records
Gather all Names/SSNs Obtain status & nationalitySequester all records early
– Medical– Dental– Behavioral health– Civilian– Radiology records
Do not permit changes “after the fact”Sequester all medical/dental imaging
evidence
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Forensic Toxicology Guidelines
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Toxicology
SAMPLES Two 10 ml red tops Three 7 ml gray tops Three 7 ml purple tops 50-70 ml urine (no preservative)(CLEAN SKIN WITH BETADINE OR SOAP/WATER – NO
ALCOHOL SWABS!)
Run local tests: glucose, BAT, CBC, SMA-18, and U/A
Follow direction of Forensic Toxicology handbook from AFMES for shipping.
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Toxicology (continued)
AFMES 1323Medication History and Mishap DetailsUse the AFMES 1323 / Verify a reliable address
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Toxicology (continued)
Chain of Custody – Have a plan for security/storage while awaiting shipment
Commercial vendors ideal for accountability/tracking
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Postmortem Examination
X-rayAutopsy
ToxicologyLabAncillary studies
(Fatalities checklist is useful from the Flight Surgeon’s Handbook)
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X-rays
Full body clothedHands/feet/head/neckPermanent evidence of injuriesAll parts/pieces of all bodies must be x-rayedSurvivors need x-rays in some cases
– ejectionDemonstrates fractures/morphology
– mechanism of injury
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Autopsy Jurisdiction
Local Coroner vs. Flight Surgeon– Coroner/ME usually has jurisdiction on/off base
Dictated by MOU’s, State laws, & SOFA (for OCONUS)
– FS can perform “over-the-shoulder”– Call AFMES for coordination
Initial Response: Remains should be tagged, photographed and removed from the field
Involve Flight Surgeon and Mortuary AffairsWith large complex mishap -- may take days
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Autopsy
Involve AFMES (Armed Forces Medical Examiner System) early
Crew members involved, preferably all victims Photography of remains as recovered Documentation of all injuries External examination of injuries Internal examination- chest, abdomen, cranial vault Dissection of soft tissue injuries Laminectomy if needed Documenting all injuries & natural disease Forms to perform autopsy available online at
www.afmes.mil
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Psychological Support Life Skills & Chaplain
– Activated by Wing/CC– CISM (Critical Incident
Stress Management) is no longer a standard approach
– Individual comfort
Mishaps with Fatalities
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NotificationResources Immediate Response Interim Safety Board
– Evidence Collection– Aircrew & Witness Interviews
Additional Considerations– PA– Mishap Classifications
Safety/Accident Investigation BoardsHuman Factors Analysis
Agenda
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Interim Safety Board (ISB)
Performs initial walk-through & secures siteGathers evidenceMirrors SIB membership
– Board President (BP) Usually OG or DO Overseeing functions of ISB
– “Investigating” Officer (IO) Usually a Wing FSO At scene, documenting/preserving evidence
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ISB (continued)
– Pilot Member (PM) Usually Sq/FSO or Wing DOV Gathering FEF folder, training records, WX, etc.
– Flight Surgeon (FS) Local Flight Doc Survivor care or helping with remains
– Maintenance Member (MM) Usually Wing/Sq Mx Officer Gathering A/C records, fluid samples, etc
Plus ... all accomplish initial interviews
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ISB Flight Surgeon Timeline
8 hour message24-48 hrs
– 72 hr & 14 day histories on all involved– Review of records & images– Notifications– Collect lab specimens & results– Preservation/shipment of items to AFIP– Interview witnesses
Begin data entry into AFSASTransfer all information/evidence to SIB FSRemain available for questions
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NotificationResources Immediate Response Interim Safety Board
– Evidence Collection– Aircrew & Witness Interviews
Additional Considerations– PA– Mishap Classifications
Safety/Accident Investigation BoardsHuman Factors Analysis
Agenda
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Evidence Collection
Observe– Do not disturb– Document people involved (aircrew & witnesses),
weatherRecord
– Photography– Sketches & Notes
CollectPreserve
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Observe
Don’t be in a hurry to move wreckage– All required photographs are taken and properly
“cataloged” – Mortuary Affairs issues/photographic support as
wreckage recovered– Technical experts need to do preliminary
work/analysis prior to moving– Need a good game plan
Note who was involved in crash and who witnessed the event
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Initial Walk Through
Meet and coordinate approach with OSC – Off-site if possible – Understand hazards
Strive for a “macro” look at the site– Key to determining follow-on support
ID all major parts– Do not disturb or move parts– Coordinate with ISB or SIB/BP if you do
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Assume “Control”
Every Situation is Different– Site Declared “Safe” by Senior Fire Official– Site may be Underwater
With No Fatalities– EOD Safe– Security Cordon– Hazards: Biological, Materiel, Environmental, etc.
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Ways to Secure the Mishap Site
If a major accident occurs on property under civil jurisdiction, the involvement of military resources in the accident gives the AF no specific rights or jurisdiction
Have PA / OSC explain to Media, Local Law Enforcement, Property Owner, etc., why we need to control site– Evidence preservation can be “weak” argument– Better approach is to explain wreckage is hazardous
and that it is for the “Protection of the public”SIB/BP or Wing/CC has authority to impound.
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Ways to Secure the Mishap Site
National Defense Area (NDA)– Sometimes a last resort
Implemented by OSC on behalf of CC– NDA temporarily places non-federal lands under effective
control of DoD– Used to protect priority resources
Mandatory for nuclear mishaps– May have to compensate landowners for “take-over”
Implement Overfly Restrictions– Notify Wing Commander– Establish a NOTAM– OSC & BP work with FAA through Base Ops
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Moving Wreckage
An installation commander may choose to remove wreckage interfering with mission activities or causing a hazard at mishap site.
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Initial Walk Through
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Initial Walk Through
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Initial “Walk Through”
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Evidence Collection
Observe– Do not disturb– Document people involved (aircrew & witnesses),
weatherRecord
– Photography– Sketches & Notes
CollectPreserve
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Photography
Purpose– Documents the mishap– Educates people who could not observe the site
firsthandRules of Thumb
– Over shoot and under print– Document each photograph!!!
Aerial Photos– CAP, Coast Guard, SAR, wing assets, alert A/C
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Photography
Digital – 8 Megapixel– Save all memory cards for future reference– Do not delete “bad” pictures
Generic Time-Sensitive Facts– Potentially significant evidence…Ground scars, etc.– Medical evidence… Human remains– Wreckage– Damage to private property (for legal purposes)– Witness’ Point-of-View
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Photography
“Required” Views– Overall View– Mid-Range – focus on the damage– Close-up– Extreme Close-up with Photographic Ruler
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Photography
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Photography…What is it?
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Photography
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Photography
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Photography
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Photography
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Evidence Collection
Observe– Do not disturb– Document people involved (aircrew & witnesses),
weatherRecord
– Photography– Sketches & Notes
CollectPreserve
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Sketches
Diagram of crash site– Work with CE– GPS for exact impact coordinates– Not necessary to plot all pieces, just critical
evidence and major pieces to get an idea of the pattern
– Should complement photographs– Use legend if it will avoid clutter– Include statements: “not to scale” and “applied
North” if applicable
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Mishap Site Diagram
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Mishap Site Diagram
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Mishap Site Diagram
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Mishap Site Diagram
I n t e g r i t y - S e r v i c e - E x c e l l e n c eAs of: 66
Evidence Collection
Observe– Do not disturb– Document people involved (aircrew & witnesses),
weatherRecord
– Photography– Sketches & Notes
CollectPreserve
I n t e g r i t y - S e r v i c e - E x c e l l e n c eAs of: 67
Collect
Methods– Grid– Zone
Evidence Tag (AF Form 52)– WHO collected specimen– WHAT condition the specimen was in when
found– WHERE specimen was collected (GPS, map
coordinates, etc.)– WHEN date and time
I n t e g r i t y - S e r v i c e - E x c e l l e n c eAs of: 68
Evidence Collection
Observe– Do not disturb– Document people involved (aircrew & witnesses),
weatherRecord
– Photography– Sketches & Notes
CollectPreserve
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Preservation
Initial Interviews– Direct Involvement: Participants, Eyewitnesses,
Wingmen, etc.– Indirect: Schedulers, Crew Chiefs, SOF,
maintenanceFluid Samples (One Pint Minimum)
– From mishap aircraft– AGE and Servicing Equipment– Originating and enroute locations– Air Refueling?
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Preservation
Other considerations:– ATC voice and RADAR tapes– Wingman’s aircraft for FDR, HUD tape, etc.– Other airborne aircraft (AWACS, Tanker, etc. )
Data Recorders– One item ISB can “work” now– AFSC will provide guidance on locating and
preserving other sources of data Engine memory, structural recorders, avionics, etc.
– Before shipping recorders for downloading…
Contact AFSC/SEFE (246-5867)
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Preservation
Accomplish TOX Testing– For Class A & B flight mishaps test aircrews– For Class A, B, or C mishaps test individuals
whose actions or inactions, in the Commander’s judgment may have been a factor
– Obtain a letter from the wing commander to authorize the collection/tox testing.
– ContractorsBy consent or if a provision of the contract
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NotificationResources Immediate Response Interim Safety Board
– Evidence Collection– Aircrew & Witness Interviews
Additional Considerations– PA– Mishap Classifications
Safety/Accident Investigation BoardsHuman Factors Analysis
Agenda
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Aircrew Interview
Documentation of medical facts should be on an SF600 and/or AHLTA. Histories may be obtained via a questionnaire developed locally.– 72 hour history (sleep/previous sorties/food)– 2 week history (stressors/circadian rhythm)
Remote Piloted Aircraft (RPA) – specific directives on collecting information on crews operating the aircraft during and preceding the event for Class A and B as well as the most recent maintenance crew. Two separate boards may be stood up at the duty station and in the area of operation as applicable.
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ISB Witness Interview
Promise of Confidentiality?“Tell me what happened”“Tell me what you saw”Few follow-on questions
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Witness Identification
Survivors / RelativesTransient WitnessesLocal EyewitnessesOn Duty witnesses
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Safety Privilege
Encourages frank & open communication with witnesses/contractors
Allows commander to quickly obtain accurate mishap information
Helps ensure appropriate corrective action
Ultimately, enhances national security and aviation safety
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Promise of Confidentiality…Two Part Promise– AFI 91-204, Chapter 3 - overview– AFI 91-204 Figure A3.3 1c.
“…my confidential statement(s) … will not be made public and it will only be used by authorized officials solely for mishap prevention purposes. … I understand, however, that my statement can be released pursuant to a valid court order on behalf of the defendant in a criminal trial. I further understand that if my statement contains an intentional misrepresentation, then my statement will no longer be considered confidential and can be used to support disciplinary and/or administrative actions against myself and/or others.”
Safety Privilege
I n t e g r i t y - S e r v i c e - E x c e l l e n c eAs of: 78
Who is Authorized to Make Promise of Confidentiality– Primary duty safety personnel – ISB and SIB members
Who may Receive Promise of Confidentiality– Any witness– Includes contractors who designed, built, or
maintained equipment
Safety Privilege
I n t e g r i t y - S e r v i c e - E x c e l l e n c eAs of: 79
When is Promise Given?– Investigator discretion to encourage witness or
contractor cooperation– Not on blanket basis to every witness
Document the Promise– Use draft templates, AFI 91-204, Chapter 2, to
document promise and to document when promise is not given
Safety Privilege
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Murphy’s Laws of Witnesses
Regardless of the physical evidence to the contrary, at least one credible witness will come forward stating the aircraft was on fire prior to ground impact
For every witness statement there will be an equal and opposite witness statement
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ISB Lessons Learned
Secure evidence and don’t tamper with it!Conduct recorded interviews with mishap
aircrew immediately– but not to the detriment of medical care!
Methodical turnover to SIB– ISB should stick around for a few days– Keep tabs on ISB members… future questions
Ensure privilege statement on initial interviews
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NotificationResources Immediate Response Interim Safety Board
– Evidence Collection– Aircrew & Witness Interviews
Additional Considerations– PA– Mishap Classifications
Safety/Accident Investigation BoardsHuman Factors Analysis
Agenda
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PA Support
Provides initial news release to media – Within one hour of mishap– Coord on all news releases and pictures– Solicits & monitors media support & interest
Guides news media’s access to mishap Site– Relationship with local media very important– OSC can’t restrict access on private property– PA can explain hazards, keep media at distance
Deflect publishing photos of remains
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Media Relations
Refer all questions to Public Affairs– Only the board president is authorized to release info
Use extreme courtesyDon’t speculate on mishap causePolitely ask civilians & media not to photograph
fatalities or classified items– Contact security forces if necessary
Refer potential claimants to JAAvoid media; let SIB/AIB do its job
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Release of Information “What Not To Say !!”
Mishap responsibilityFailure of equipment or facilitiesLegal liability of the governmentClassified informationCauses, factors or recommendationsFactors not causal in the mishapStatements, quotations or opinions from witnesses
or other privileged sources
Bottomline: “Please refer to PA.”
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Mishap Classification
Classify mishaps by– Direct Cost– Fatality, severity of Injury or degree of illness
Class of Mishap– A, B, or C as well as Class E physiologicals
If mishap class in doubt– AF Safety Center can (and will!) assist
Access to experts to determine “best guess” dollar estimate
AFI 91-104 1.10
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Class A Mishap
Destroyed aircraftGreater than $1 M in damages to airframeFatality or permanent total disability of crew
or passengers
AFI 91-104 1.10 87
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Class B Mishap
Greater than $200k in damagePermanent partial injury to crew or
passengersHospitalization of three or more people
AFI 91-104 1.10 88
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Class C Mishap
Greater than $20 K damageLost work day or days
AFI 91-104 1.10 89
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Class D Mishap
Restricted work day or days
AFI 91-104 1.10 90
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Class J Mishap
Engine mishapsForeign Object Damage, BASH
AFI 91-104 1.10 91
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Class E Mishap
Events that don’t meet A, B, or C criteriaTrending for safety/mishap prevention
Physiologic incidents
AFI 91-104 1.10 92
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Scenario Discussion
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Scenario Discussion
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Scenario Discussion
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Scenario Discussion
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Scenario Discussion
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Scenario Discussion
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Scenario Discussion
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Scenario Discussion
I n t e g r i t y - S e r v i c e - E x c e l l e n c e 101
NotificationResources Immediate Response Interim Safety Board
– Evidence Collection– Aircrew & Witness Interviews
Additional Considerations– PA– Mishap Classifications
Safety/Accident Investigation BoardsHuman Factors Analysis
Agenda
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Purpose of Investigation
Find underlying cause/explanation Future mishap preventionImprove risk management/ORMImprove safety processPreservation of combat resources
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I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Safety Investigations
NOT To Fix BlameNOT Merely to Gather EvidenceNOT Used for Disciplinary Purposes
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I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Safety Mishap Investigation Boards
Interim Safety Board (ISB)– Preserve evidence until permanent safety board arrives– Gather pertinent data that may be lost over time– Accomplish initial actions for permanent board
Wing Mishap Response Plan (MRP)– Lists ISB member duties– Checklists available for all base agencies
Safety Investigation Board (SIB) - AFI 91-204– Mishap prevention– Determine cause(s)– Recommend corrective actions– Privileged report, partially
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I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Accident Mishap Investigation Board
Accident Investigation Board (AIB) - AFI 51-503– Claims & litigation– Disciplinary action– Adverse administrative actions– Publicly releasable report
105
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Board Composition
Full Board - Class A, full compliment of members
Tailored Board- only the required board members (determined by convening authority)
Single investigator- when formal board not required
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I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Board Member Selection
ISB Chosen By WG/CCSIB Appointed by MAJCOM/CC
– Safety Office Researches Availability Annotates Adverse Impact To Individual And / Or Wing Seeks Members With Desire To Be Chosen Always A Short Notice Suspense
– Wing CC Approves Local List Submitted To MAJCOM
– MAJCOM/CC Appoints
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I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Members
Board President (Rated Colonel or O-7 for Fatality) Investigating OfficerMaintenance MemberMedical OfficerPilot MemberAFSC RepresentativeRecorderTechnical Assistance Members As Required
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I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Flight Surgeon Role
Medical expert for board members Liaison to Mortuary Affairs/AFIPTeam leader for all Life SciencesAdvisor for:
– Search & Rescue Team (SAR)– Human factors– Human survivability– Aircrew medical qualification– Lifestyle– Crew rest analysis
Family liaison
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I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Flight Surgeon Liaison
Flight surgeon jobLocal coroner/MELocal emergency medical careLocal FS/interim boardPathologyAFIP consultant for investigation,
photography, and autopsy
110
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Medical Analysis/Pathology
AutopsyForensic identificationDental evaluationDNA analysisPhotographyExamination of flight/life support gearEvaluates medical history/evidenceDetermines circumstances of death
111
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Flight Surgeon Role4-6 week commitment PLUS presentations later on Interview or history-taking expert on boardAssist Line board members in understanding human
issues/factors involved in mishapConsultations (aerospace physiology, aviation psychology,
life support)Assist survivors, direct/indirect
– Victims– Families– Board
Team supportData entry into AFSASTab Y
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I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Accident & InjuryAccident & Injury
Latent Conditions
Latent Conditions
Latent Conditions
Active Conditions
Failed orAbsent Defenses
After Reason (1990)
HAZARDHAZARD
Swiss Cheese Model
OrganizationalInfluences
Supervision
Preconditions
Acts
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I n t e g r i t y - S e r v i c e - E x c e l l e n c e
DoD Human Factors (HFACS)
ActsErrorsViolations
SupervisionInadequate SupervisionPlanned Inappropriate OperationsFailure to Correct Known ProblemsSupervisory Violations
PreconditionsEnvironmental FactorsCondition of IndividualsPersonnel Factors
Organizational InfluencesResource/Acquisition ManagementOrganizational ClimateOrganizational Processes
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I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Fly Awake / FAST Program
As of: 115
I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Simulations
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I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Schweaty’s Bullets
Gain operational SA– Your assigned airframe– Other assigned airframes
Check your AFSAS– Sign up for notifications on airframes of interest.– Gain familiarity with the interface.
Get involved with Safety office– The first time you meet your wing or flight safety officer should not
be in the field!– Participate in monthly or quarterly flight safety meetings.
Clarify and Exercise your capabilities.– Involve MDG and other wing players.– Ensure MOU’s in place with respective AD bases for ANG/AFR and
local community/host nation if needed
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I n t e g r i t y - S e r v i c e - E x c e l l e n c e 118
Review
NotificationResources Immediate Response Interim Safety Board
– Evidence Collection– Aircrew & Witness Interviews
Additional Considerations– PA– Mishap Classifications
Safety/Accident Investigation BoardsHuman Factors Analysis